Healthcare Provider Details

I. General information

NPI: 1104874452
Provider Name (Legal Business Name): SRINIVASAN DEVANATHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8028 CARNEGIE BLVD. SUITE 600
FORT WAYNE IN
46804-5790
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-969-7100
  • Fax: 260-969-7263
Mailing address:
  • Phone: 260-266-6013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number01059028A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number01059028A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01059028
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: